Accreditation Corner

PREPARING FOR DMEPOS ACCREDITATION: Human Resource Management

By Harry Lattanzio, R.Ph.

When CMS released the Quality Standards for Suppliers of DMEPOS in August of 2006, the idea was to ensure that accredited suppliers (pharmacies included) provide quality products and services to beneficiaries in a safe and cost effective way. In order to achieve this, CMS wanted suppliers to ensure that their employees were performing at an optimal and efficient level. To put it simply, CMS wants suppliers to institute good business practices and this applies to Human Resource practices as well.

The Accreditation Organizations (AOs) have taken the Human Resource Management Subsection from the CMS Quality Standards and created their own Human Resource Standards. In these Standards, the AOs have the pharmacy create formal policies, procedures and practices to become compliant with the AOs Standards. Through compliance with these standards CMS will be satisfied that the pharmacy and its employees are meeting their expectations. Some of the AO requirements are discussed below.

Personnel Files
Accurate and up-to-date personnel files, as in any sound business, need to be maintained. Training certificates/acknowledgements, background information, education credentials, tax information and all other employee specific information should be kept within the file. These files should be kept in a secure area and accessible by appropriate staff members. A 3-file system can be utilized to separate medical, financial (payroll), and general personnel information to eliminate staff from viewing more sensitive or confidential information.

Background Investigations and Medicare Exclusion List
Pharmacies are required to conduct background investigations on all current employees and new hires and crosswalk the employees with the Medicare Exclusion list on a yearly basis and prior to hiring an individual. Failure to ensure that an employee is not on the Exclusion list may result in penalties from CMS and often-time repayment of reimbursements dating back to the start date of that employee (that could be a couple years). Can you afford to pay back two years worth of Medicare Reimbursements?

Training
All pharmacy personnel involved in the provision of DMEPOS to beneficiaries must be properly trained for the DMEPOS supplied by the pharmacy. Since an employee will be training the beneficiary/caregiver, the pharmacy must ensure that the employee is proficient in the use, maintenance, and cleaning of the product. Another key component to this training is ensuring that pharmacy personnel can provide this training to beneficiaries and/or their caregivers according to their abilities, learning preferences, language preference, and readiness to be trained. Documentation is crucial for all training whether it be for pharmacy personnel or the beneficiary/caregiver.

Performance Review and Corrective Actions
Annual performance reviews will need to be conducted for each employee. The purpose for this review is to provide the pharmacy employee with feedback on his or her performance, while providing the opportunity to improve in any areas that are lacking. The performance review not only encompasses the employee s ability to perform their job but also a review of beneficiary complaints, satisfaction surveys, and billing/coding errors pertaining to that individual. If necessary, additional training should be conducted, or at least the opportunity for the employee to seek additional training (through seminars or videos).

AO surveyors will also be looking at documentation of corrective actions taken by management. CMS wants to ensure that the pharmacy is taking measures to ensure that the same errors are not reoccurring. This corrective action will require the review of past data (e.g., beneficiary surveys, product training proficiency tests, and billing/coding errors log) to determine if corrective action is needed. Corrective action can be as simple as providing additional training or in the extreme, termination of the employee.

Other Compliance Criteria
This article provides just a general overview of Human Resource issues that you must address with accreditation. Other criteria to consider in regard to Human Resource Management is to ensure that the pharmacy has adequate staffing levels, documentation of pharmacy personnel injuries, license and certification verification, driving record of the delivery driver, infection control, cultural awareness, and job descriptions. All criteria listed within needs to be formalized with a written policy and procedure and forms/logs (when applicable). This is followed by instituting the practices contained within your policies and procedures if you are not currently practicing them and training your staff on these policies and procedures and practices. Lastly, ongoing compliance and documentation is crucial.

Final Thought
The AO standards provide basic guidelines that reflect the practices of a business with solid Human Resource management. Accreditation can be tedious and time consuming, however having a fully functional human resource section will definitely be worth the investment. This will actually help protect pharmacies from making costly hiring mistakes and possibly aid with employee retention. Spending the necessary time and resources compiling and organizing the information can save a tremendous amount of time and money by ensuring you have the best employees working for your pharmacy. In the end, the beneficiary is provided with professional, trained, and properly credentialed personnel to provide them with their DMEPOS. And, the pharmacy has a satisfied customer that will continue to bring his business to your pharmacy!

The author, Harry A. Lattanzio, R.Ph., is president of PRS Pharmacy Services and owns both retail and LTC pharmacies. He has given numerous seminars throughout the country on preparing a pharmacy to pass the DMEPOS Accreditation survey.

For more information on how PRS can help save you time and money with preparing your pharmacy for accreditation, visit us at www.prsrx.com.